Glucagon infusion in refractory anaphylactic shock in patients on beta-blockers Report by Martin Thomas, Specialist Registrar Checked by Ian Crawford, Senior Clinical Fellow

EDs in the UK are not prepared for emerging biological threats and bioterrorism. With current facilities and procedures it is highly likely that an infectious agent will spread to staff and other patients in any future biological incident.

Objective: To achieve consensus in all phases of chemical incident planning and response. Design: A three round Delphi study was conducted using a panel of 39 experts from specialties involved in the management of chemical incidents. Areas that did not reach consensus in the Delphi study were presented as synopsis statements for discussion in four syndicate groups at a conference hosted by the Department of Health Emergency Planning Co-ordination Unit. Results: A total of 183 of 322 statements had reached consensus upon completion of the Delphi study. This represented 56.8% of the total number of statements. Of these, 148 reached consensus at .94% and 35 reached consensus at .89%. The results of the process are presented as a series of synopsis consensus statements that cover all phases of chemical incident planning and response. Conclusions: The use of a Delphi study and subsequent syndicate group discussions achieved consensus in aspects of all phases of chemical incident planning and response that can be translated into practical guidance for use at regional prehospital and hospital level. Additionally, areas of non-consensus have been identified where further work is required.

The 125 synopsis consensus statements that all phases of biological incident planning and response. These can be used to inform policy decisions and translated into practical guidance for emergency planners and first responders at local, regional and national levels.

A report is presented on a five-state study of 1,201 drownings during a 12-month period ending June 30, 1966. More than a score of variables involved were analyzed and the findings are discussed. The need for more valid information and for further studies along various lines is emphasized. AN

A short cut review was carried out to establish whether intubation is always required in patients presenting with a decreased conscious level after c-hydroxybutyrate ingestion. Altogether 95 papers were found using the reported search, of which two presented the best evidence to answer the clinical question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these best papers are tabulated. A clinical bottom line is stated.

Background: Early decontamination (DECON) on site, triage, second DECON at hospitals and emergency treatment are required for dealing with chemically contaminated mass casualties. Purpose: To introduce the activities planned for dealing with chemically contaminated, massive numbers of casualties at the hospital and on-site of the exposure. Methods: The planning, training, and exercises to treat massive numbers of chemically contaminated casualties that were developed and conducted after the 11 September 2001 attacks were reviewed. Results: a. DECON showers and outlets of compressed air were set at the bottom of the parking building. Casualties doff their dress at this area. Wet DECON for massive numbers of casualties was conducted using showers and fire engines in the parking area, DECON shelters, and a DECON room inside of the hospital. The type of Wet DECON administered was determined according to severity. Exercises were performed according to the plan using trained, medical procedures wearing level "C" Personnel Protective Equipment (PPE). b. An exercise was conducted with the Tokyo Fire Department in order to coordinate with the HAZMAT teams and EMT/Paramedics on-site. Triage and emergency treatment were conducted at the warm zone and temporary care tents in cold zone. Conclusions: At the hospital, preparing DECON shelters was time consuming. For the treatment of massive numbers of casualties, multiple DECON facilities should be prepared including rapid undressing and wet DECON using fixed showers. It is important to play a role in spite of the lack of PPEs, equipment, and a communication system, since Japanese paramedics are not able to provide a full complement of medical care.

A woman aged 67 years attended the emergency department with acute abdominal and back pain of 1-day duration with associated vomiting. The patient had multiorgan failure. Resuscitation was started with intravenous fluids and vasopressors. An abdominal CT scan was completed which confirmed the diagnosis of acute gastric volvulus. The patient was successfully resuscitated from a cardiorespiratory arrest during transfer to the operating theatre. The patient subsequently underwent a total gastrectomy with stapling of the oesophageal and duodenal stumps. The abdomen was packed and left open as a laparostomy with a planned relook 48 hours later was to be performed. Unfortunately, the patient continued to deteriorate postoperatively in the intensive care unit despite maximum organ support for multiorgan failure. A decision was made to withdraw treatment and the patient died 10 hours postoperative. This case illustrates the presentation of acute gastric volvulus at a late stage and the high mortality rate associated with it.